Clinical Practice Guidelines: Obstetrics/Physiological cephalic birth · 2020-02-12 · HR, BP, Temp, PV loss and fundal check − every 15 mins • If the mother consents, clamp

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Policy code CPG_OB_PHB_0220

Date February, 2020

Purpose To ensure consistent management of a physiological cephalic birth.

Scope Applies to all Queensland Ambulance Service (QAS) clinical staff.

Health care setting Pre-hospital assessment and treatment.

Population Applies to all ages unless specifically mentioned.

Source of funding Internal – 100%

Author Clinical Quality & Patient Safety Unit, QAS

Review date February, 2023

Information security UNCLASSIFIED – Queensland Government Information Security Classification Framework.

URL https://ambulance.qld.gov.au/clinical.html

Clinical Practice Guidelines: Obstetrics/Physiological cephalic birth

https://ambulance.qld.gov.au/clinical.html

167QUEENSLAND AMBULANCE SERVICE

Physiological cephalic birth

Normal birth is defined by the World Health Organisation as:

• spontaneous in onset

• low-risk at the start of labour

• remaining low-risk throughout labour and birth

• the newborn is born:

- spontaneously- in the vertex position- between 37 and 42 completed weeks gestation

• after birth, the woman and newborn are in good condition.[1]

Risk assessment

Gaining adequate antenatal history may pre-empt complications associated with birth, including:

• gestational diabetes (macrosomic baby,shoulder dystocia risk)

• mal-presentation

• multiple pregnancy

• pre-eclampsia

• placenta praevia

• perinatal substance use

• history of obstetric or gynaecological disorderor emergency.

Ensure an aseptic technique and always use appropriate infection control measures.

Clinical features

February, 2020

Figure 2.40

Single newborn presenting via the vertex

Signs of imminent birth

• loss of operculum plug – when the cervix dilates,the mucous plug (‘bloody’ show) dislodges fromthe cervical canal (may have occurred days before)

• increasing frequency and severity of contractionswith an urge to push, or open bowels

• membrane rupture (this may not occur and activemembrane rupture will be required if the head hasbeen delivered with the membrane intact)

• bulging perineum

• appearance of the presenting part at the vulva.

NOTE – If birth is imminent due to trauma, refer to CPG: Trauma in pregnancy.

UNCONTROLLED WHEN PRINTED UNCONTROLLED WHEN PRINTED UNCONTROLLED WHEN PRINTED UNCONTROLLED WHEN PRINTED


Additional information

• Support the mother to find a position of comfort (lying lateral,

or on all fours).

• Following spontaneous rupture of membranes the vagina

should be visually inspected for cord presentation or prolapse

– ask the mother to feel for the cord.

• Support controlled breathing through-out the contractions

– encourage the mother to push with each contraction as

she feels the urge.

• Manage delivery in accordance with CPP: Physiologicalcephalic delivery.

Care of the newly born (postnatal care):

e

• Thoroughly dry the newborn, wipe the eyes and assess thenewborn’s breathing.

• If the newborn is crying or breathing effectively (chest rising atleast 30 times per minute) leave the newborn with the mother.If the newborn is not breathing effectively, immediately referto CPG: Resuscitation – Newly born.

• Ensure the newborn is kept warm and heat loss is minimised– if required use the baby blanket and beanie from theQAS ‘Maternity Pack’.

• Assess neonatal and maternal observations:

- Neonatal observations: APGAR (at 1 and 5 minutes),HR, RR, Temp and muscle tone − every 15 mins

- Maternal: HR, BP, Temp, PV loss and fundal check− every 15 mins

• If the mother consents,

clamp the cord at 10, 15

and 20 centimetres from

the newborn and cut

between 15 and 20

centimetres.

• Provide a safe

warm environment

with uninterrupted

skin to skin contact.

Encourage breast

feeding to

promote the

production of

maternal oxytocin.

• Cord clamping and cutting:

- Late cord clamping and cutting (3−5 minutes following birth)is recommended for all births, while initiating simultaneousessential neonatal care. Immediate cord clamping (< 1 minutefollowing birth) should only be performed if the newly bornis asphyxiated and needs to be moved immediately forresuscitation.[4,5,6,7]

- Some mothers may request the cord remain intact with placentaattached (not clamped or cut). This request should be respectedunless the newborn is required to be moved for resuscitation.


e


Application ofcord traction

Placenta visible

Guarding uterus

Application of cord tractionuntil the placenta is visible

Active management of the third stage of labour (oxytocin administration)

a) Promote maternal production of oxytocin by providing a safe, warm environment with uninterrupted skin to skin contact between mother and baby, and encourage breastfeeding.

b) Administer oxytocin (refer to DTP: Oxytocin).

c) Observe for and confirm signs of placental separation:

- The uterus rises in the abdomen

- The uterus becomes firmer and globular (ballotable)

- Fresh show/trickle of blood

- Lengthening of the umbilical cord.

d) Delivery of the placenta.

- Assist the mother to birth the placenta by her own efforts. Encourage her to adopt an upright position, bearing down to expel the placenta; OR

- Guard the uterus by placing one hand suprapubically and applying steady controlled cord traction until the placenta is visible. Support the birth of the placenta and membranes by gently twisting to strengthen the placenta and limit the chance of retained products – do not apply increased traction if resistance is felt.

e) Retain the placenta for visual inspection by the midwife and/or doctor.

f) Complete a fundal assessment:

• If the uterus is soft – massage the fundus until it is firm and central. Consider asking the mother to pass urine, as a full bladder can inhibit the contraction of the uterus. Fundal massage is only to be performed following delivery of the placenta.

• If the uterus is firm – do not massage the fundus as this may cause further bleeding and pain for the mother.

g) Assess and estimate blood loss (normally around 200–300 mLs).

Additional information (cont.)



NOTE: If blood loss exceeds 500 mL, refer toCPG: Primary postpartum haemorrhage

Physiological management of the third stage of labour (refusal of oxytocin)

a) Promote maternal production of oxytocin by providing a safe, warm environment with uninterrupted skin to skin contact between mother and baby,and encourage breastfeeding.

b) Assist the mother to birth the placenta naturally by her own efforts. Encourage her to adopt an upright position, bearing down to expel the placenta.

c) Do not apply cord traction.

d) Once the placenta has been delivered, retain for visual inspection by the midwifeand/or doctor.

e) Complete a fundal assessment:

• If the uterus is soft – massage the fundus until it is firm and central. Consider asking the mother to pass urine, as a full bladder can inhibit the contraction of the uterus. Fundal massage is only to be performed following delivery of the placenta.

• If the uterus is firm – do not massage the fundus as this may cause further bleeding and pain for the mother.

f) Assess and estimate blood loss (normally around 200–300 mLs).

e Additional information (cont.)


CPG: Paramedic safety

CPG: Standard cares

Patient in labour?

Signs of imminent birth?

Ensure controlledbirth of head

• allow mother to assume a comfortable position

• prepare equipment

• consider analgesia

CONDUCT POST-BIRTH ASSESSMENT AND CARES:

• Dry baby

• Maintain warmth

• Provide maternal and baby skin to skin contact

• Clamp and cut the cord,when pulsation ceases

• Manage third stage of labour

• APGAR score at 1 & 5 mins

Continually reassessduring transport

Note: Officers are only to perform procedures for which they have received specific training and authorisation by the QAS.

N

Breech presentation

N

Coard prolapsed? Y

Y

N

Y

Y

Transport to hospital

Pre-notify as appropriate

Manage as per:

• SuctionCPG: Cord prolapse

Manage as per:

• SuctionCPG: Breech birth

N

Shoulder obstructed?

Cord loop around neck?(nuchal cord)

Y

Y

Manage as per:

• SuctionCPP: Nuchal umbilical cord

Manage as per:

• SuctionCPP: Shoulder dystocia

Consider:

• SuctionOxytocin

Baby birthed

N

Is the amniotic fluid clear?

• good breathing/crying• good muscle tone AND• HR > 100

Y

Y

Manage as per:

• SuctionCPP: Resuscitation − Newly born

N

N


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Clinical Practice Guidelines: Obstetrics/Physiological cephalic birth · 2020-02-12 · HR, BP, Temp, PV loss and fundal check − every 15 mins • If the mother consents, clamp